Orchard Valley Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Hendersonville, North Carolina.
- Location
- 200 Heritage Circle, Hendersonville, North Carolina 28791
- CMS Provider Number
- 345285
- Inspections on file
- 29
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Orchard Valley Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to accurately code MDS assessments for hospice and PASRR status for multiple residents. Several residents who had elected or been admitted to hospice, and who had current hospice recertifications, were not coded on their quarterly or significant change MDS assessments as receiving hospice care or as having a condition with a life expectancy of less than six months. Another resident with a documented Level II PASRR determination was not coded on the annual MDS as having a serious mental illness and/or intellectual disability or related condition. Facility MDS staff acknowledged these omissions as oversights, while leadership stated they expected accurate MDS coding.
Surveyors found that quarterly MDS assessments were not completed within the required timeframe for three residents, with each assessment finalized more than 14 days after the ARD. Review of electronic records showed delayed completion dates for these quarterly assessments, and during interviews the MDS RN and regional clinical staff confirmed the assessments were late. Staff reported that a high volume of new admissions contributed to falling behind on required MDS work, and leadership acknowledged that additional improvement was needed to ensure timely completion.
A resident admitted with multiple mental health diagnoses, including schizoaffective disorder, anxiety, depression, bipolar disorder, schizophrenia, OCD, and insomnia, and receiving antianxiety medications, did not receive a requested Level II PASRR evaluation. The admission MDS reflected active psychiatric/mood disorder diagnoses, and psychiatric NP notes documented ongoing treatment for anxiety, depression, and bipolar disorder. The SW reported that her usual practice was to review diagnoses and medications and submit PASRR requests through NCMUST for residents with mental health diagnoses, but acknowledged that this resident was overlooked during an audit. The Administrator stated that the expectation was for the SW to review all residents admitted with a Level I PASRR and mental health diagnoses and submit them for Level II re-evaluation, which did not occur in this case.
The facility failed to request Level II PASRR reevaluations for two residents with serious mental illness after significant changes in condition were identified on MDS significant change assessments. Both residents had existing Level II PASRR determinations with no expiration date and were receiving psychotropic medications, yet NC MUST records showed no reevaluation requests following the documented changes. The SW, who was responsible for PASRR submissions, reported being unaware that a significant change in condition required a Level II PASRR reevaluation, and the Administrator confirmed that the SW was designated to review diagnoses and request reevaluations per regulatory guidelines.
Surveyors found that the facility failed to complete current bed rail assessments and obtain informed consent before installing and using bed grab bars for two residents with chronic pain, mobility limitations, and range of motion impairments. In both cases, quarterly MDS assessments documented specific assistance needs with bed mobility and indicated that bed rails were not used as restraints, yet observations showed bed grab bars in upright positions being used either for independent repositioning or to assist staff during care. Electronic records lacked informed consent for bed grab bar use, and the most recent bed rail assessments were months old, documented no expressed desire for assistive devices, and did not reflect the actual use of the grab bars. Interviews with CNAs, the DON, the Unit Manager, and the Administrator confirmed the residents’ use of the devices and revealed confusion about assessment frequency and unawareness of the requirement to obtain informed consent prior to installation.
A resident with incomplete quadriplegia, chronic pain, and a height of 73 inches was repeatedly observed in bed with the head elevated, legs straight, and feet pressed against the footboard, causing discomfort. The resident, who was cognitively intact and dependent on staff for bed mobility and self-care, reported that his feet hurt and stated he had requested a longer bed multiple times, as well as asking staff to place pillows under his feet. A NA and a medical assistant confirmed the resident’s ongoing complaints and their use of pillows to relieve pressure when the head of the bed was raised. During an observation with the DON, the resident again stated the bed was too small, and the DON acknowledged the bed appeared too small and that the resident’s feet were pressed against the footboard. The DON also noted the resident had previously been in a longer bed before a room change but could not explain why he was later placed in a shorter bed, and a work order for a longer bed was not initiated until the surveyor’s inquiry.
A resident with vascular dementia and severe protein-calorie malnutrition experienced significant weight loss while under orders for fortified pudding, frozen nutritional cups, and a house supplement for weight stability. Despite these physician and RD-directed orders, surveyors observed that the resident’s lunch trays did not include the fortified pudding or frozen nutritional cups, and meal tickets lacked these items. A CNA confirmed the supplements were not being served, the Dietary Manager acknowledged the orders but reported no recollection of receiving diet requisition forms needed to enter them into the Meal Tracker system, and the nourishment room did not contain the ordered products. The MD, RD, DON, and Administrator all stated they expected ordered nutritional supplements to be provided.
A resident with vascular dementia and dysphagia was not provided with an updated care plan reflecting physician-ordered changes to a mechanical soft diet with nectar thick liquids and pureed meats. Despite recommendations from the Speech Therapist and new physician orders, the care plan continued to list a regular diet with thin liquids, and staff responsible for updating care plans were unaware of the changes.
A resident with dementia and dysphagia, who required nectar thick liquids due to aspiration risk, was served thin liquid hot tea instead of the ordered consistency. The error was identified by a nurse aide after reviewing the meal card, and confirmed by dietary and therapy staff as a failure to follow the physician's order for nectar thick liquids.
The facility failed to provide meals according to the approved menu, affecting residents on regular, mechanical soft, and puree diets. Observations revealed missing ingredients in shepherd's pie and incorrect portion sizes during breakfast service. Dietary staff did not follow the approved menu or seek necessary approvals for substitutions, leading to deficiencies in meal service.
The facility failed to maintain cleanliness and proper food handling procedures, with observations revealing dried stains on floors and improper food labeling and storage. Expired food items were found, and open food items were not labeled, dated, or covered. The Dietary Manager cited staff shortages as a contributing factor, while the Administrator expected cleanliness and proper food handling.
The facility did not notify the Regional Ombudsman of resident discharges or transfers for six months, affecting 150 residents. The responsibility for notifications was in transition between staff members who subsequently left, leading to the oversight. The Administrator and DON attempted to cover the roles but failed to send the required notifications.
The facility failed to ensure timely physician visits every 30 days for the first 90 days of admission for four residents with various medical conditions. The deficiency was due to an unreliable system for tracking regulatory visits, exacerbated by staff turnover. The DON was temporarily managing the process, but oversight occurred, and the MD was unaware of the missed visits.
The facility failed to maintain a safe and clean environment, with unsecured and non-functional overbed lights, unsanitary bathroom conditions, and furniture in disrepair. The maintenance manager was unaware of many issues due to a lack of communication, and the housekeeping supervisor admitted to not consistently verifying staff work. The administrator and DON expected a clean environment, but the survey revealed significant deficiencies.
The facility failed to complete MDS assessments within the required timeframe for several residents due to staff turnover and increased workload. Additionally, a resident's CAA was submitted without necessary analysis for a triggered care area. The issues were acknowledged by the MDS Coordinator and the Director of Nursing.
The facility failed to complete quarterly MDS assessments within the required timeframe for several residents due to high turnover in MDS staff positions. This led to significant delays in completing assessments, as MDS Nurses had to cover additional responsibilities typically handled by other team members. The Administrator confirmed that the backlog was present upon his arrival and was worsened by further staff departures.
The facility failed to involve two residents in their care planning process. One resident with intact cognition and another with moderate cognitive impairment were not invited to participate in care plan meetings following their MDS assessments. The facility's administrator noted that the social worker responsible for scheduling these meetings had left, and the schedule had not been updated, leading to undocumented meetings.
A resident with diabetes and renal dialysis dependence did not receive the prescribed renal diet due to a failure in the facility's meal tracking system. The resident was served restricted items like potatoes and orange juice, which were not listed on the meal tray ticket due to a system error. Staff interviews confirmed the oversight, and the resident expressed dissatisfaction with the meals provided.
A resident with severe cognitive impairment and bedridden status was unable to access a light switch due to a broken cord, which was not reported or repaired in a timely manner. Staff were aware of the issue but failed to notify maintenance, relying instead on a wall switch. The DON expected staff to report such issues promptly to ensure resident accessibility.
A resident's advanced directives were inconsistent across their care plan and medical records. Despite having a DNR status on the MOST form and electronic health record, the care plan listed the resident as Full Code. Staff interviews revealed confusion over responsibility for updating directives, with the DON assuming the role due to a vacant social worker position.
A resident with bacteremia had a UA ordered, but the results were not obtained due to a failure in communication and process. The nurse collected the specimen but did not ensure it was processed, and the NP was not informed of the missing results. The DON and Administrator acknowledged the communication breakdown, but the resident did not suffer harm.
A resident reported inappropriate touching by another resident, but the incident was not immediately reported to the Administrator as required by the facility's abuse policy. The nurse documented the incident in a progress note but failed to notify the DON or Administrator promptly, leading to a delay in reporting to the State Agency and law enforcement.
The facility failed to renew PASRR evaluations and update care plans for two residents with mental health diagnoses. A resident with schizoaffective disorder and another with schizophrenia had expired PASRR Level II determinations, and their care plans did not reflect these determinations. The Social Worker responsible for PASRR oversight had left, and the RDCS was unaware of the expired evaluations.
Two residents with intact cognition and a desire to return to the community were not provided with adequate discharge planning due to the absence of a Social Worker. Despite being approved for Medicaid programs to assist with their transition, no discharge care plans were developed, and the residents did not receive the necessary support to complete applications or set up appointments. The facility's Administrator and DON attempted to fill the gap but failed to document conversations or update the residents on their discharge plans.
A resident with diabetes mellitus and moderately impaired cognition experienced increased confusion and weakness. Despite guidance to check blood sugar, Nurse #5 did not do so, nor did they report the resident's use of hypoglycemic medication to the on-call MD. The resident was later found to have hypoglycemia at the hospital. Interviews with facility staff revealed an expectation that blood sugar should have been checked as part of the assessment.
A resident requiring a mechanical lift and two-person assistance for transfers was manually transferred by a single NA without assistance, contrary to the care plan. The NA, an agency staff member, was misinformed by another NA and did not receive proper orientation, leading to the unsafe transfer.
A resident with an indwelling urinary catheter was found to have the catheter tubing unsecured, despite a physician's order to use an anchoring device every shift. The resident confirmed the device was not routinely applied, and although nurses documented it as secure, it was revealed that the resident often removed it. This inconsistency led to the identification of a deficiency during a survey.
A resident with chronic conjunctivitis missed five doses of prescribed Moxifloxacin eye drops due to a delay in pharmacy delivery. The delay was caused by a refill request being too soon for insurance coverage, and the necessary payment authorization form was not submitted in time. The resident's eye condition worsened during this period, although it was not painful or itchy.
A resident with chronic conjunctivitis missed five doses of prescribed Moxifloxacin eye drops due to a delay in pharmacy delivery. Despite the nurse's efforts to refill the medication promptly, it was not included in shipments, leading to missed doses. The DON was not informed in time to address the issue.
A resident's urinalysis was not completed due to a nurse failing to fill out the necessary requisition form, resulting in the specimen not being collected by the lab. The DON found the uncollected specimen in the refrigerator, and the NP was not informed about the missing lab results. The Administrator expected proper documentation and communication to ensure lab orders are processed.
A resident in an LTC facility, who was cognitively intact, had a care plan indicating a preference for double protein portions. Despite this, the resident reported not receiving the larger portions requested. The Dietary Manager was aware of the request but failed to update the meal ticket, resulting in the resident receiving standard portions. The Regional Director of Operations and the Director of Nursing were unaware of the issue, and the Administrator expected staff to honor residents' preferences, highlighting a communication breakdown.
A resident with a right-hand muscle contracture did not have a splint applied as required by a physician's order, despite documentation indicating otherwise. Observations on two days showed the absence of the splint, and a nurse admitted to possibly signing off on the MAR by accident. The DON and Administrator expected accurate documentation and explanations if the splint was not applied.
The facility lacked a qualified Activity Director, affecting all 106 residents. The Assistant Activity Director and Activity Assistant, both without formal training or degrees, were unaware of the requirements. The Administrator confirmed the absence of a qualified AD since August, with temporary roles filled by untrained staff. Interviews for a new AD were ongoing.
The facility failed to complete MDS assessments and entry tracking records within the required timeframes for two residents due to significant staff turnover. The deficiency was confirmed by MDS nurses and the Administrator, who noted that the assessments were already behind when he started, and further staff departures worsened the situation.
The facility failed to ensure privacy for residents in two semi-private rooms. In one room, there was no track for a privacy curtain, preventing its installation. In another, the curtain did not fully extend due to incorrect installation of track wheels. Both issues were confirmed by staff and acknowledged by the Administrator as communication and reporting failures.
A resident with severe cognitive impairment was not protected from sexual abuse by another resident with moderate cognitive impairment. The male resident was found in bed with the female resident, with clothing displaced, indicating an intention to engage in sexual activity. The male resident's known wandering behavior was not adequately supervised, contributing to the incident. The facility staff intervened after the incident, but the deficiency highlights a failure to protect residents from abuse.
A LTC facility failed to preserve evidence in a potential sexual assault case involving two residents with cognitive impairments. Staff provided incontinence care and discarded potential evidence, focusing on maintaining the dignity of the female resident. The facility's policy on abuse and evidence preservation was not followed, affecting the investigation's integrity.
A facility with 134 certified beds failed to employ a qualified full-time Social Worker (SW) as required. The SW hired did not have the necessary bachelor's degree in social work or a related field, holding only an associate's degree in medical billing and coding. The Administrator, new to the facility, was aware of the regulation but had not addressed the issue. The Vice President of Operations cited recruitment challenges and noted that the Administrator and a SW at a nearby facility could provide support.
Inaccurate MDS Coding for Hospice and PASRR Status
Penalty
Summary
The deficiency involves the facility’s failure to accurately code Minimum Data Set (MDS) assessments for hospice status and PASRR Level II determinations for four residents. One resident who had been initially admitted to hospice and recertified for continued hospice services did not have hospice services reflected on a quarterly MDS assessment. Another resident, admitted to hospice several months earlier and recertified for hospice services, had a quarterly MDS that did not indicate a condition or chronic disease with a life expectancy of less than six months and did not show that hospice care was being received. A third resident elected hospice services, as documented in a hospice agreement, and a significant change MDS was completed due to this election; however, the MDS did not indicate that the resident was receiving hospice care. The facility also failed to accurately code PASRR information for a fourth resident. This resident had a Level II PASRR determination letter with no expiration date, but the annual MDS assessment did not reflect that the resident was currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. In interviews, the Regional MDS Consultant, MDS Coordinator, and MDS RN acknowledged that each of these MDS assessments should have reflected the residents’ hospice status or Level II PASRR status and characterized the errors as oversights. The DON and Administrator each stated they expected MDS assessments to be coded accurately.
Untimely Completion of Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD) for three of thirty sampled residents. For one resident, the electronic medical record showed a quarterly MDS with an ARD of 09/29/25 that was not marked as completed until 10/22/25. For a second resident, the quarterly MDS had an ARD of 11/15/25 and was not completed until 12/04/25. For a third resident, the quarterly MDS had an ARD of 11/07/25 and was not completed until 12/02/25. These completion dates exceeded the regulatory timeframe tied to the ARD for quarterly assessments. During a joint interview on 02/19/26, the MDS RN and Regional MDS Consultant confirmed that the quarterly MDS assessments for these three residents were not completed within the required regulatory timeframe. The MDS RN stated that the facility had experienced a high volume of new admissions and that staff had fallen behind on the number of MDS assessments needing completion. In a subsequent interview on 02/20/26 with the Administrator present, the Regional Director of Clinical Operations acknowledged that, despite good-faith efforts to address MDS issues, further improvement was still needed in completing assessments within regulatory timeframes.
Failure to Request Level II PASRR Evaluation for Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident admitted with multiple mental health diagnoses. Documentation showed the resident had a Level I PASRR determination with no expiration date and was admitted with schizoaffective disorder, anxiety, depression, and bipolar disorder. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, yet listed active psychiatric/mood disorder diagnoses including anxiety, depression, bipolar disorder, and schizophrenia, and the resident was receiving antianxiety medications. Subsequent psychiatric nurse practitioner notes documented a history of obsessive compulsive disorder (OCD), schizophrenia, bipolar disorder, major depressive disorder, schizoaffective disorder, anxiety, and insomnia, and ongoing treatment for anxiety, depression, and bipolar disorder. Despite these documented mental health conditions and ongoing psychiatric treatment, there was no evidence that the facility submitted a request for an updated Level II PASRR evaluation for this resident. The social worker reported that her process was to review diagnoses and medications for new admissions and submit to the North Carolina Medicaid Uniform Screening Tool (NCMUST) when a resident had a mental health diagnosis, and that she had many Level II PASRRs at the facility and a PASRR office contact for questions. She stated she had conducted an audit when she started in August 2025 and acknowledged that this resident was overlooked. The administrator stated that the expectation was for the social worker to review all residents admitted with a Level I PASRR and a mental health diagnosis and submit them for re-evaluation for a Level II PASRR, which did not occur for this resident.
Failure to Request PASRR Level II Reevaluations After Significant Changes in Condition
Penalty
Summary
The facility failed to request Level II PASRR reevaluations after significant changes in condition for residents already determined to have Level II PASRR status. One resident with schizoaffective disorder, bipolar type, and anxiety disorder had a Level II PASRR determination with no expiration date and was identified on a significant change MDS assessment as having a serious mental illness, with active anxiety disorder and schizophrenia, and receiving antipsychotic and antidepressant medications. Despite this significant change assessment, a review of the NC Medicaid Uniform Screening Tool (NC MUST) showed that no PASRR reevaluation request had been submitted following the significant change. Another resident with major depressive disorder and anxiety disorder also had a Level II PASRR determination with no expiration date and was similarly identified on a significant change MDS assessment as having a serious mental illness, with active anxiety disorder and depression and receiving antianxiety and antidepressant medications. NC MUST records again showed no PASRR reevaluation request after the significant change assessment. During interviews, the Social Worker, who was responsible for submitting Level II PASRR reevaluation requests, stated she was still learning the PASRR process and was not aware that a reevaluation request was required when a resident had a significant change in condition. The Administrator confirmed that the Social Worker was responsible for reviewing diagnoses and requesting Level II PASRR reevaluations when residents experienced significant changes in condition per regulatory guidelines.
Failure to Complete Bed Rail Assessments and Obtain Informed Consent for Bed Grab Bars
Penalty
Summary
The deficiency involves the facility’s failure to complete required bed rail assessments and obtain informed consent prior to installing and using bed grab bars for two residents. Facility policy required that different approaches be tried before using a bed rail and, if a bed rail was needed, that the resident be assessed for safety risk, risks and benefits be reviewed with the resident or representative, informed consent be obtained, and the bed rail be correctly installed and maintained. For both residents cited, surveyors found bed grab bars in use without documentation of informed consent in the electronic medical record and with outdated bed rail assessments that did not support the current use of the devices. One resident had chronic respiratory failure with hypoxia, muscle weakness, chronic pain, intact cognition, and lower extremity range of motion impairment. A quarterly MDS showed he required supervision or touching assistance with bed mobility, was independent with moving from sitting to lying, and did not use bed rails as a physical restraint. During observations, a bed grab bar was seen secured in the upright position on the right side of his bed while he was sleeping and later while he was sitting up eating breakfast. The last bed rail assessment, dated many months earlier, documented that neither the resident nor his representative expressed a desire for an assistive device, that he could independently reposition in bed, and that alternatives to bed rails had not been attempted because a bed rail would promote mobility and transfers. Staff interviews confirmed he used the bed grab bar independently for repositioning and bed mobility, yet no informed consent for its use was found in his record. The second resident had rheumatoid arthritis and lumbar intervertebral disc degeneration with discogenic back and lower extremity pain, intact cognition, and range of motion impairment in both upper and lower extremities. A quarterly MDS indicated he was always incontinent of bowel and bladder, dependent on staff for toileting hygiene, required supervision or touching assistance with rolling, and partial to moderate assistance with position changes, with bed rails not used as a physical restraint. Observations showed bilateral bed grab bars in the upright position, which the resident and staff reported he used only to hold onto while staff rolled him for care, not for independent repositioning. The last bed rail assessment, completed months earlier, documented that neither the resident nor his representative expressed a desire for an assistive device, that he could not rise independently from a supine position, could not reposition himself in bed, had balance and trunk control problems, and that a PT consult had been attempted as an alternative. However, there was no evidence of informed consent for the bed grab bars, and interviews with the DON, Unit Manager, and Administrator revealed uncertainty and lack of awareness regarding assessment frequency and the requirement to obtain informed consent before installation.
Failure to Provide Properly Sized Bed to Accommodate Resident Needs
Penalty
Summary
The facility failed to reasonably accommodate a resident’s need for an appropriately sized bed, resulting in the resident’s feet pressing against the footboard whenever he was in his usual position. The resident, who was 73 inches tall and had incomplete quadriplegia at C5–C7 with chronic pain due to trauma, was cognitively intact and dependent on staff for self-care, bed mobility, and transfers. On multiple observations, the resident was seen in bed with the head of the bed elevated about 30 degrees, his head positioned approximately two inches below the top of the bed, and his legs straight with his feet pressed against the footboard. The resident reported that his feet hurt when they pressed against the footboard and stated he had requested a longer bed multiple times, as well as asking NAs to elevate his feet on pillows to relieve the discomfort. Staff interviews confirmed that the resident had repeatedly expressed discomfort and requested pillows under his feet because of the pressure against the footboard. A NA and a medical assistant both stated that when the head of the bed was raised, the resident’s feet pressed into the footboard and that they used pillows to elevate his feet at his request. During an observation with the DON, the resident again stated the bed was too small, and the DON acknowledged that his feet were pressed against the footboard, that the bed appeared too small, and that he could be at risk for skin breakdown. The DON also stated the resident had previously been in a longer bed before a room transfer but could not explain why he received a shorter bed afterward. The Maintenance Director reported that nursing staff were responsible for assessing bed size and entering work orders for larger beds, and confirmed that a work order for a longer bed for this resident was not received until the date of the survey interview, indicating that prior requests and observations had not resulted in timely accommodation.
Failure to Provide Ordered Nutritional Supplements for Weight-Stable Care
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered nutritional supplements to a resident with vascular dementia and severe protein-calorie malnutrition who was experiencing significant weight loss. The resident had physician orders for fortified pudding after lunch beginning in June and frozen nutritional cups twice daily beginning in December for weight stability, and later an order for a house supplement (fortified shake) four times daily. Weight records showed a decline from approximately 154 pounds in early December to 133.8 pounds in early February, and the RD documented an 11.9% weight loss over three months. The RD and Medical Director both stated they expected the resident to receive all ordered supplements, and the RD noted the resident was usually consuming 51–75% of meals and was to receive fortified pudding once daily, house supplement three times daily, and frozen nutritional cups twice daily. Surveyor observations and staff interviews showed that the ordered fortified pudding and frozen nutritional cups were not being provided with the resident’s meals. On multiple observed lunch trays, the resident received a mechanically altered meal with nectar thick liquids but did not receive fortified pudding or a frozen nutritional cup, and a nurse aide confirmed these items were not on the lunch tray despite the resident eating about 75% of meals over the prior two weeks. Review of the meal ticket confirmed the supplements were not listed. The Dietary Manager acknowledged the resident had physician orders for fortified pudding and frozen nutritional cups and that these should have been on the tray, but stated she had no recollection of receiving a diet requisition form from nursing to add them to the Meal Tracker system. The Unit Manager could not recall whether diet requisition forms had been submitted for these supplements, and an observation of the nourishment room showed no stock of fortified pudding or frozen nutritional cups. The Medical Director, DON, and Administrator each stated they expected residents to receive nutritional supplements as ordered.
Failure to Update Care Plan for Physician-Ordered Diet Changes
Penalty
Summary
The facility failed to update the care plan to reflect the current diet as ordered by the physician for a resident with vascular dementia and dysphagia. The resident was admitted with moderate cognitive impairment and required partial to moderate assistance with eating. The care plan, last revised on 4/23/25, indicated a regular diet with thin liquids, but did not reflect subsequent changes in the physician's orders. On 05/27/25, the physician ordered a mechanical soft diet with nectar thick liquids due to overt signs and symptoms of aspiration, and on 05/28/25, pureed meats were added to the diet order. Despite these changes, the care plan was not updated to reflect the new dietary orders. The Speech Therapist evaluated the resident and recommended the diet downgrade due to high risk for aspiration, and both the MDS Coordinator and DON confirmed that the care plan should have been updated. The MDS Coordinator was unaware of the changes to the diet orders and acknowledged responsibility for updating care plans, indicating a lapse in communication and care plan revision processes.
Failure to Provide Ordered Nectar Thick Liquids to Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with vascular dementia and dysphagia, who was assessed as moderately cognitively impaired and at high risk for aspiration, was not provided with fluids consistent with the physician's order. The resident's care plan and physician's order specified a mechanical soft diet with nectar thick liquids due to overt signs and symptoms of aspiration. However, during a lunch observation, the resident's meal tray included a cup of thin liquid hot tea instead of the required nectar thick consistency. The nurse aide delivering the tray did not initially notice the inconsistency and only realized the error after reading the meal card, which specified nectar thick hot tea. The resident did not consume the tea, and it was removed from the tray. Interviews with dietary staff and the speech therapist confirmed that the resident's order was for nectar thick liquids and that the thin liquid tea was an oversight by dietary staff. The facility used pre-thickened fluids to avoid such errors, but in this instance, the correct consistency was not provided. The speech therapist had previously evaluated the resident and recommended nectar thick liquids due to a high risk of aspiration. Both the DON and the Administrator acknowledged that the resident should have been served nectar thick liquids as per the physician's order.
Deficiency in Meal Service and Menu Adherence
Penalty
Summary
The facility failed to provide all food items as specified by the approved menu and did not ensure residents received the correct portion sizes based on the approved menu. During an observation of the lunch meal tray line, it was noted that the shepherd's pie served to residents on regular and mechanical soft diets lacked mixed vegetables and onions, which were part of the approved recipe. The dietary staff member responsible for preparing the meal stated that he did not include these ingredients because they were unavailable and followed guidance from a former Regional Director of Operations (RDO) who did not include them in the recipe. The Dietary Manager and current RDO confirmed that the shepherd's pie should have contained all the items called for in the recipe, or the Dietary Manager should have been notified to obtain approval for appropriate substitutions. Additionally, during the breakfast meal service, the facility did not follow the approved menu for both regular and puree diets. The regular diet menu called for two slices of French toast, one sausage patty, and six ounces of oatmeal, while the puree diet menu specified pureed French toast, pureed sausage, and pureed oatmeal. However, observations revealed that residents on regular diets received only one piece of French toast, scrambled eggs, and grits instead of oatmeal, without proper approval for these substitutions. Similarly, residents on puree diets did not receive pureed French toast or sausage, and the pureed eggs served did not contain cheese as approved by the Registered Dietician (RD). Interviews with dietary staff and the RDO indicated a lack of communication and adherence to the approved menu and portion sizes. The RD confirmed that a contract company handled food preparation and she was not involved in day-to-day kitchen operations. The facility's Administrator expressed an expectation that dietary staff follow approved recipes and notify supervisors if ingredients are unavailable to allow for appropriate substitutions. However, the failure to adhere to these expectations resulted in deficiencies in meal service for residents on regular, mechanical soft, and puree diets.
Deficiencies in Cleanliness and Food Handling Procedures
Penalty
Summary
The facility failed to maintain cleanliness and proper food handling procedures in various areas, including the walk-in cooler, walk-in freezer, dry storage room, kitchen, and nourishment rooms. Observations revealed multiple dried stains on the floors of these areas, and the Dietary Manager attributed the lack of cleanliness to the absence of two staff members due to illness. The Administrator expressed an expectation for all kitchen floors to be clean and free of stains. Additionally, the facility did not adhere to proper food labeling, dating, and storage practices. Expired food items, such as pasteurized eggs and bread, were found in the walk-in cooler and kitchen, respectively. Open food items in the walk-in freezer and reach-in coolers were not labeled, dated, or covered, and milkshakes lacked use-by dates. The Dietary Manager acknowledged these issues and cited staff shortages as a contributing factor. The facility also failed to maintain clean food preparation areas and equipment. The bottom shelves of food preparation tables were found with scattered food crumbs and dried stains, and the reach-in coolers had dried and smeared stains on their doors. The nourishment room refrigerators and freezers contained dried stains, and the Dietary Manager confirmed that it was the dietary department's responsibility to clean these areas. The Administrator expected all food preparation areas and equipment to be clean and free of debris.
Failure to Notify Ombudsman of Resident Transfers/Discharges
Penalty
Summary
The facility failed to notify the Regional Ombudsman of resident discharges or transfers for six consecutive months, from April to November 2024. This deficiency was identified through a review of the facility's Admission/Discharge reports, which showed that a total of 150 residents were discharged or transferred during this period. The Administrator admitted that there was no documentation of notifications being sent to the Regional Ombudsman. The responsibility for sending these notifications was in transition from the Admissions Director to the Social Worker, but both individuals left their positions, leaving the Administrator and the Director of Nursing to cover these roles. This oversight resulted in the failure to notify the Ombudsman as required.
Failure to Ensure Timely Physician Visits for New Admissions
Penalty
Summary
The facility failed to ensure that physician visits were conducted every 30 days for the first 90 days of admission for four residents. Resident #21, with diagnoses including chronic obstructive pulmonary disease and heart failure, was only seen by the MD twice during the first 90 days. Resident #31, who had diabetes and chronic kidney disease, was also seen only twice in the same period. Resident #41, with conditions such as chronic obstructive pulmonary disease and dementia, was seen once during the first 90 days and not again until after the 90-day period. Resident #55, with hemiplegia and diabetes, was seen twice during the first 90 days. The deficiency was attributed to a lack of a reliable system to track and ensure compliance with regulatory visit requirements. The Director of Nursing (DON) was temporarily managing the tracking of MD visits due to turnover in the Medical Records and Social Worker positions. The DON provided the MD with weekly reports of admissions and discharges, but the system was not foolproof, leading to oversight of required visits. The MD confirmed that he relied on the facility's list of admissions to determine which residents needed to be seen and was unaware that the required visits for the four residents had not been completed as per regulations.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple deficiencies observed during the survey. In several rooms, overbed light fixtures were not secured to the wall, posing a risk of injury to residents if they were to fall. Additionally, many of these light fixtures were non-functional, and the maintenance manager was unaware of these issues until they were pointed out during the survey. The maintenance manager relied on staff to report such issues, but there was a clear lack of communication and follow-up, leading to unresolved maintenance problems. The survey also revealed significant cleanliness issues within the facility. In one shared bathroom, there was a persistent and overwhelming odor resembling urine, and the toilet and surrounding areas were visibly dirty with dried stains. Despite daily cleaning routines, these issues persisted over several days, indicating a failure in housekeeping practices. The housekeeping supervisor acknowledged the problem but admitted to not being able to verify the work of her staff consistently. This lack of oversight contributed to the unsanitary conditions observed. Furthermore, the facility's furniture and fixtures were found to be in poor repair. Several rooms had furniture with exposed sharp edges due to missing wood or broken plastic, which posed a safety hazard to residents. The maintenance director was not aware of these issues, as he depended on nursing staff to report them. Additionally, the facility had damaged walls and ceilings with missing textured spackling, which were not addressed in a timely manner. The administrator and director of nursing expressed expectations for a clean and well-maintained environment, but the survey findings highlighted a disconnect between these expectations and the actual conditions within the facility.
Delayed MDS Assessments and Incomplete CAA in LTC Facility
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required 14-day timeframe for several residents. Specifically, the assessments for Residents #6, #16, #21, #28, #29, #47, #68, and #78 were not completed within the regulatory time frame. The delays in completing these assessments were confirmed by MDS Nurses during interviews. The primary reason for the delay was attributed to turnover in the MDS staff and the need for the remaining staff to cover additional responsibilities typically handled by other members of the Interdisciplinary Team. Additionally, the facility failed to comprehensively complete the Care Area Assessment (CAA) for Resident #89. The significant change in status MDS assessment for this resident was submitted without the necessary analysis of findings for the triggered care area of psychotropic drug use. The MDS Coordinator acknowledged this oversight and explained that the assessment was submitted by a former coordinator, and she was unable to provide further details on how the error occurred. The Administrator and Director of Nursing were aware of the issues with MDS assessments. The Administrator noted that the assessments were already behind when he assumed his position, and the Director of Nursing emphasized the importance of completing CAAs comprehensively. Despite efforts to address the backlog, the facility continued to struggle with timely completion of MDS assessments due to staff turnover and increased workload.
Delayed MDS Assessments Due to Staff Turnover
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required 14 days of the Assessment Reference Date (ARD) for 14 out of 45 sampled residents. This deficiency was identified through a review of electronic medical records and staff interviews. The residents affected by this deficiency had their MDS assessments completed significantly later than the regulatory timeframe, with delays ranging from several weeks to over a month. The deficiency was primarily attributed to high turnover in the MDS staff positions, which led to a backlog in completing the assessments. MDS Nurse #1, who was responsible for assisting with the assessments, reported that she was only able to work at the facility once a week and had to cover multiple facilities. Additionally, the turnover affected other members of the Interdisciplinary Team, requiring the MDS Nurses to complete sections of the assessments typically handled by others, further contributing to the delays. The facility's Administrator confirmed that the MDS assessments were already behind when he assumed his position. The situation was exacerbated by the departure of a full-time and a part-time MDS Nurse, which further delayed the completion of assessments. Despite efforts to catch up, the facility struggled to maintain timely assessments, especially during periods of increased admissions.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to invite residents to participate in the development and implementation of their person-centered care plans. Specifically, two residents were not invited to attend care plan meetings or provide input regarding their care plans. Resident #50, who has intact cognition and was admitted with diagnoses including diabetes and anxiety disorder, was not invited to care plan meetings following her annual and quarterly MDS assessments. The comprehensive care plan for Resident #50 was last revised several months prior, and the resident confirmed she had not been invited to a care plan meeting since June 2024. Similarly, Resident #11, who has moderate cognitive impairment and was admitted with diagnoses including congestive heart failure and major depressive disorder, was not invited to participate in care plan meetings following her quarterly MDS assessment. The last documented care plan meeting for Resident #11 involved her family member and occurred several months prior, with no subsequent meetings scheduled. The facility's administrator acknowledged that the social worker responsible for scheduling these meetings had left the facility, and the care plan meeting schedule had not been updated since then. Despite some meetings being conducted, they were not documented in the residents' medical records.
Failure to Provide Prescribed Renal Diet
Penalty
Summary
The facility failed to provide a resident with a renal diet as ordered by the physician. The resident, who was admitted with diagnoses including diabetes and dependence on renal dialysis, had a specific diet order that excluded certain foods such as potatoes, tomato sauce, and orange juice. However, observations revealed that the resident was served meals containing these restricted items. The resident confirmed receiving inappropriate foods and expressed dissatisfaction with the meals provided. Interviews with facility staff, including the Dietary Manager and the Regional Director of Operations, revealed that the computerized meal tracking system failed to print the restricted items on the resident's meal tray ticket. This oversight led to dietary staff being unaware of the resident's specific dietary restrictions. The Registered Dietician and other staff members, including the Director of Nursing and the Administrator, acknowledged the expectation that the resident should have received the diet as ordered, but the system error resulted in the resident not receiving the correct diet since the order change.
Failure to Ensure Resident Accessibility to Light Switch
Penalty
Summary
The facility failed to accommodate the needs of a dependent resident, who was unable to access a light switch located on the left side of her bed. The resident, who had severe cognitive impairment and was bedridden, could not reach the switch cord, which was only 3 inches in length and positioned 5 feet from the floor. This issue persisted for over a month, as the resident had to rely on staff to control the light fixture. Despite the resident's condition and the importance of accessibility, the broken switch cord was not reported or addressed in a timely manner. Staff interviews revealed that a nurse aide was aware of the broken switch cord but did not notify the maintenance staff, instead using a wall switch near the entrance door to control the light. The maintenance manager, who conducted weekly checks, was unaware of the issue and relied on verbal or work order reports for repairs. The Director of Nursing expected staff to be attentive to residents' living environments and report repair needs promptly, emphasizing the importance of accessibility for dependent residents.
Inconsistent Advanced Directives for Resident
Penalty
Summary
The facility failed to maintain accurate advanced directives for a resident, leading to a discrepancy in the resident's care plan. The resident, who was severely cognitively impaired, had a Medical Orders for Scope of Treatment (MOST) form indicating a Do Not Resuscitate (DNR) status, signed by the responsible party. However, the resident's care plan listed them as Full Code, which was inconsistent with the MOST form and the electronic health record that also indicated a DNR status. Interviews with facility staff revealed a lack of clarity and responsibility regarding the updating of advanced directives. The Director of Nursing (DON) had assumed the responsibility for updating advanced directive care plans due to the absence of a social worker, but the discrepancy remained unaddressed. The Administrator and other staff members acknowledged the expectation for consistency across all areas of the resident's chart, but the inconsistency persisted, highlighting a breakdown in communication and responsibility within the facility's processes.
Failure to Notify Physician of Incomplete Urinalysis
Penalty
Summary
The facility failed to notify the Physician when a urinalysis (UA) was not completed for a resident who was admitted with a diagnosis that included bacteremia. The resident had a physician's order for a UA with culture and sensitivity due to urinary pain, which was ordered and marked as completed. However, upon review, there were no lab results for the UA. Nurse #6, who collected the specimen, stated that she placed it in the refrigerator for lab collection but was unaware that there were no results, and thus did not notify the Physician. The Nurse Practitioner (NP) was also not informed that the UA results were missing and expressed that she would have wanted to be notified if the UA was not completed or needed to be reordered. The Director of Nursing (DON) identified that the breakdown occurred because the requisition was not filled out, and the Administrator expected that the NP would be notified if a lab order did not reach the lab. The resident did not experience harm or a negative outcome due to the UA not being completed.
Failure to Immediately Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to adhere to its abuse policy and procedure by not immediately reporting an allegation of resident-to-resident abuse to the Administrator. The policy required that all alleged violations involving abuse or resulting in serious bodily injury be reported to the Administrator immediately, but not later than two hours after the allegation is made. In this case, a resident reported that another male resident entered her room and touched her inappropriately. The incident was documented by a nurse in a progress note, but there was no indication that the Director of Nursing (DON) or Administrator was notified at the time of the report. The progress note was written by a nurse on a later date, indicating a delay in reporting the incident. The facility became aware of the allegation only after the resident reported it again, leading to a delay in notifying the State Agency and law enforcement. Interviews with the involved nurse and facility staff revealed discrepancies in the reporting timeline, with the nurse unable to recall the incident and the DON not being informed promptly. This delay in reporting violated the facility's policy and procedure for handling abuse allegations.
Failure to Renew PASRR and Update Care Plans
Penalty
Summary
The facility failed to request a Preadmission Screening and Resident Review (PASRR) before the expiration date and did not develop comprehensive care plans that incorporated Level II PASRR determinations for two residents. Resident #21, who was admitted with schizoaffective disorder and anxiety disorder, had a PASRR Level II Determination Notification that expired without a new evaluation being requested. Additionally, Resident #21's comprehensive care plan did not address the Level II PASRR determination. The facility's Social Worker, who was responsible for overseeing the PASRR process, had left employment, and the Regional Director of Clinical Services (RDCS) was temporarily handling the PASRR requests. However, the RDCS was unaware of the expired PASRR for Resident #21. Similarly, Resident #104, admitted with schizophrenia, major depressive disorder, and post-traumatic stress disorder, had a PASRR Level II determination that expired without a new evaluation being requested. The comprehensive care plan for Resident #104 also failed to address the Level II PASRR determination. The RDCS, who was managing the PASRR process in the absence of a Social Worker, was not aware of the expired PASRR for Resident #104 until an audit was conducted. The Administrator acknowledged that care plans should have been developed to address the Level II PASRR determinations, but the turnover in the Social Worker position led to these oversights.
Lack of Discharge Planning for Residents
Penalty
Summary
The facility failed to implement a discharge planning process that involved the residents in developing a discharge care plan addressing their goals and post-discharge needs. Resident #50, who was admitted with diagnoses including diabetes, chronic pain, PTSD, and anxiety disorder, had intact cognition and expressed a desire to return to the community. Despite being approved for a Medicaid program to assist with the transition, there was no active discharge plan in place. The resident lost a housing assistance voucher due to delays and was not provided with the necessary support to complete applications or set up appointments, as the facility lacked a Social Worker to assist with these tasks. Similarly, Resident #70, with a chronic autoimmune disease, history of falls, and seizure disorder, also had intact cognition and aimed to return to independent living. Although approved for a Medicaid program, the discharge planning process stalled due to the absence of a Social Worker. The resident needed help applying for housing, but no staff member was available to assist, and no discharge care plan was developed. The facility's Administrator and Director of Nursing attempted to fill the gap left by the Social Worker's departure but did not document conversations or update the residents on their discharge plans. The facility's failure to develop and update discharge care plans for these residents resulted from the absence of a Social Worker, which left the residents without the necessary support to achieve their discharge goals. The Administrator acknowledged the oversight and confirmed that discharge care plans should have been developed and updated as the residents' plans progressed. The lack of documentation and communication with the residents further contributed to the deficiency in discharge planning.
Failure to Monitor Blood Sugar in Diabetic Resident
Penalty
Summary
The facility failed to obtain a blood sugar level as part of a change of condition assessment for a resident diagnosed with diabetes mellitus, who was being treated with oral blood glucose-lowering medication. The resident, who had moderately impaired cognition, was admitted with diagnoses including diabetes mellitus, chronic kidney disease, and chronic systolic congestive heart failure. On a specific day, the resident exhibited increased confusion and general weakness, prompting an evaluation using the SBAR (Situation Background Assessment Recommendation) tool. Although the SBAR included guidance to check the blood sugar, this was not done. Nurse #5 documented the resident's condition and vital signs but did not check the blood sugar level, despite the resident's history of diabetes and use of hypoglycemic medication. The nurse also failed to report the resident's use of oral hypoglycemic medication to the on-call MD. Later, the resident's daughter took the resident to the hospital, where the resident was found to have hypoglycemia, with blood sugar levels significantly below the normal range. The resident was treated with intravenous and oral glucose, and the hypoglycemic medication was discontinued. Interviews with the Nurse Practitioner, Medical Director, and Director of Nursing revealed that they expected the blood sugar to be checked as part of the assessment, especially given the resident's medical history. The Medical Director and DON acknowledged that it was an oversight by the nurse not to check the blood sugar, which should have been included in the assessment reported to the on-call MD. The Administrator also expected that the blood sugar level would be obtained and included in the assessment.
Failure to Ensure Safe Transfer of Resident
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, identified as Resident #4, who was dependent on a mechanical lift with two-person assistance for transfers. Despite this requirement, Nurse Aide (NA) #8, an agency staff member, manually transferred Resident #4 from a geriatric chair to her bed without assistance or the use of a mechanical lift. This action was observed during a continuous observation period and was contrary to the resident's care plan and Kardex, which both specified the need for a mechanical lift and two-person assistance. NA #8, who had been working at the facility for about a month, stated she was informed by another NA that Resident #4 required only a one-person assist for transfers. She also revealed that she did not receive any orientation upon hire and was unaware of what a Kardex was or how to access it. The Director of Nursing (DON) confirmed that Resident #4 required a mechanical lift and two-person assistance for transfers and that this information was accessible to all staff via the Kardex. The DON also mentioned that an orientation book was available at each nurse's station, and staff were expected to sign a document acknowledging receipt of orientation upon hire.
Failure to Secure Urinary Catheter Tubing
Penalty
Summary
The facility failed to ensure that the urinary catheter tubing was properly secured to prevent movement and trauma for a resident with an indwelling urinary catheter. The resident, who was admitted with obstructive and reflux uropathy, had a physician's order to secure the catheter tubing using an anchoring device every shift. Despite this order, during an observation, it was found that the anchoring device was not in place, and the resident confirmed that it was not routinely applied. The care plan indicated that the resident was at risk of complications and required the catheter to be secured, yet this was not consistently done. Nurses had initialed the Medication Administration Record (MAR) to indicate that the catheter tubing was secure, but during an interview, a nurse revealed that the resident would remove the anchoring device. The Nurse Practitioner and Director of Nursing both expected the device to be in place if the MAR was checked, but acknowledged that the resident had a history of removing it. This discrepancy between the MAR documentation and the actual practice led to the deficiency being identified during the survey.
Failure to Administer Prescribed Eye Drops
Penalty
Summary
The facility failed to ensure that a resident received prescribed antibiotic eye drops, resulting in five missed doses. The resident, who had chronic conjunctivitis and moderate cognitive impairment, was prescribed Moxifloxacin eye drops to be administered twice daily. However, due to a series of communication and procedural errors, the medication was not delivered on time, leading to missed doses over several days. The issue began when a nurse realized the medication was running low and requested a refill from the pharmacy. The pharmacy indicated that the refill was too soon for insurance coverage, but the facility could pay for it. Despite this, the necessary form to authorize payment was not submitted in time to meet the pharmacy's delivery cutoff, causing further delays. The nurse and the Director of Nursing were not adequately informed of the situation, which contributed to the delay in resolving the issue. During this period, the resident's eye condition was observed to worsen, with increased redness and drainage, although it was not painful or itchy. The resident expressed concern about the missed doses, especially with an upcoming eye surgery. The Medical Director was aware of the situation and did not anticipate negative outcomes from the missed doses, but the deficiency in medication administration was evident due to the facility's failure to ensure timely delivery and administration of the prescribed medication.
Failure to Administer Prescribed Eye Drops
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident who missed five doses of prescribed antibiotic eye drops. The resident, who had chronic conjunctivitis, was supposed to receive Moxifloxacin eye drops twice daily. However, due to a delay in the pharmacy's delivery of the medication, the resident missed doses on multiple occasions. The issue began when a nurse realized the medication was running low and requested a refill from the pharmacy. Despite the nurse's efforts to ensure timely delivery, the medication was not included in the subsequent shipments, leading to missed doses. Interviews with staff revealed that the nurse had contacted the pharmacy multiple times to inquire about the missing medication, but the issue was not resolved promptly. The Director of Nursing stated that she should have been notified earlier to follow up with the pharmacy. The Medical Director was aware of the situation and noted that while the resident was not expected to experience negative outcomes from the missed doses, the medication was necessary for treating the resident's conjunctivitis. The administrator acknowledged that the nurse should have informed the DON immediately when the medication was not delivered as expected.
Failure to Complete Urinalysis Due to Missing Requisition
Penalty
Summary
The facility failed to complete an ordered urinalysis (UA) for a resident who was admitted with a diagnosis of bacteremia. The resident had a physician's order for a UA with culture and sensitivity, which was documented as completed in the treatment administration record. However, upon review, there were no lab results available for the UA. Nurse #6 collected the specimen and placed it in the refrigerator for lab collection but did not fill out the necessary requisition form, which led to the specimen not being collected by the lab. The Director of Nursing (DON) discovered the uncollected specimen in the refrigerator and noted the absence of a requisition form as the reason for the oversight. The Nurse Practitioner (NP) was not informed about the missing lab results and expressed a desire to be notified in such situations. The Administrator expected the nursing staff to complete all necessary paperwork to ensure lab orders are processed and communicated to the NP if issues arise. The failure to complete the UA was attributed to the nurse's omission of the requisition form, resulting in the specimen not being sent for analysis.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, specifically regarding portion sizes, for a resident who was cognitively intact and able to communicate his needs. The resident, admitted on 06/06/24, had a physician's order for a regular diet and a care plan indicating a preference for double protein portions. Despite this, the resident reported that he rarely received the larger portions he requested. On 12/02/24, the resident expressed his dissatisfaction with the dietary department's failure to provide the requested portion sizes, and on 12/03/24, he was observed receiving a standard breakfast portion without the requested double protein. The Dietary Manager acknowledged awareness of the resident's request for larger portions but failed to update the meal ticket accordingly. The resident was offered additional food only after all other residents had been served, which did not meet his immediate needs. Interviews with the Regional Director of Operations and the Director of Nursing revealed a lack of awareness and communication regarding the resident's dietary preferences, with the Director of Nursing noting that the care plan had not been updated due to the resident's recent hospitalizations. The Administrator also expressed an expectation that staff should honor residents' food preferences, indicating a breakdown in communication and execution of care plans within the facility.
Failure to Accurately Document Splint Application
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with a diagnosis of contracture of muscle in the right hand. A physician's order required the application of a right-hand splint, with specific instructions for its use and monitoring. However, observations on two separate days revealed that the resident did not have the splint applied, despite documentation in the Medication Administration Record (MAR) by a nurse indicating that the splint was applied on those days. During interviews, the nurse admitted to possibly signing off on the MAR by accident and acknowledged that the splint was not applied as documented. The nurse also confirmed that the order did not allow for the splint to be applied as tolerated, and there was an option to document if the resident did not tolerate the treatment. The Director of Nursing and the Administrator both expressed that they expected the splint to be applied if documented as such, and if not, a note should be written explaining why it was not applied.
Lack of Qualified Activity Director in Facility
Penalty
Summary
The facility failed to have a qualified professional to direct its activity program, which had the potential to affect all 106 residents. The Assistant Activity Director, who started working at the facility in October 2024, had no formal training or college degree and was unaware that the previous Activity Director was only acting in that role. The Assistant Activity Director could not provide details of any training received from the acting AD. Additionally, the Activity Assistant, who began working at the facility in late November 2024, also lacked formal training, a college degree, or state training courses, although she had some prior experience with adults with disabilities. The Administrator confirmed that the facility had been without a qualified Activity Director since August 2024, following the departure of the previous AD and Activity Assistant. During this period, the Admission Coordinator and evening receptionist temporarily assumed the roles of acting AD and Activity Assistant, respectively, without formal training. The Administrator acknowledged the facility's non-compliance with the regulation requiring a qualified AD and was in the process of conducting interviews to fill the position. However, at the time of the report, the facility remained without a qualified professional to direct the activity program.
Delayed MDS Assessments Due to Staff Turnover
Penalty
Summary
The facility failed to complete a discharge-return anticipated Minimum Data Set (MDS) assessment and entry tracking records within the regulated timeframes for two residents. Resident #47's discharge-return anticipated MDS assessment and entry tracking record were not completed within the regulatory timeframe, as they were marked completed on 07/23/24, despite the entry tracking record being dated 07/02/24. Similarly, Resident #83's entry tracking record dated 11/06/23 was not completed until 11/14/23, which was also outside the required timeframe. The deficiency was attributed to significant turnover in the MDS staff positions, which led to delays in completing the assessments. MDS Nurse #1, who was floating between several facilities, confirmed that the assessments fell behind due to the need to cover sections typically completed by other members of the Interdisciplinary Team, who were also affected by turnover. The Administrator acknowledged that the MDS assessments were already behind when he started in June 2024, and further staff departures exacerbated the issue. Despite efforts to catch up, the facility struggled to maintain timely completion of MDS assessments due to ongoing staffing challenges.
Privacy Curtain Deficiencies in Semi-Private Rooms
Penalty
Summary
The facility failed to provide adequate privacy for residents in two semi-private rooms, as observed during a survey. In room [ROOM NUMBER]-A, there was no ceiling mounting track for a privacy curtain, preventing the installation of a curtain around bed 207-A. This issue was confirmed by a nurse aide and the Maintenance Manager, who both acknowledged the absence of the necessary track. The resident in this room expressed a desire for a privacy curtain to block hallway light, indicating the importance of this feature for their comfort. In room [ROOM NUMBER], the privacy curtain for bed 304-A did not fully extend due to a malfunction in the mounting track. The curtain got stuck where the track curved, a problem that had been reported by the resident to nursing staff and maintenance. The Maintenance Manager identified that the wheels in the track were installed incorrectly, causing the curtain to get stuck. The Administrator later acknowledged issues with staff communication and reporting of environmental problems, which contributed to the oversight of these deficiencies.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a female resident with severe cognitive impairment from sexual abuse by a male resident with moderate cognitive impairment. The male resident was found in bed with the female resident, with his shorts pulled down and her gown and brief displaced, suggesting an intention to engage in sexual activity. The female resident, who was unable to move on her own, was found in a position that indicated she had been moved by the male resident. This incident was discovered by a nurse who immediately intervened and removed the male resident from the room. The male resident had a history of wandering behaviors, which were not adequately addressed by the facility staff. On the night of the incident, he was observed walking around the facility and was not under proper supervision, despite his known tendency to roam. The nurse assigned to the male resident's care was informed of his wandering behavior but failed to recognize it as a potential risk for abusive behavior. This lack of recognition and response contributed to the incident occurring. The facility staff, including the Director of Nursing and Assistant Director of Nursing, were notified of the incident, and law enforcement was contacted. The female resident was assessed for injuries, and although no immediate physical harm was noted, a forensic examination later revealed a rectal tear. The male resident was placed under one-to-one supervision following the incident, but the facility's failure to prevent the situation highlights a significant deficiency in protecting residents from abuse.
Removal Plan
- Resident #1 was removed from Resident #2's room and returned to his room where he was placed on 1:1 staff supervision.
- Notifications made to Administrator who ensured appropriate reporting requirements were made to the NC DHHS agency, local police department and Adult Protective Services.
- Resident #2 was assessed by LN #1 for signs of injury and no concerns were noted.
- Emergency Medical Services (EMS) was called and Resident #2 was transported to the hospital for further examination.
- The QAPI Committee held an Ad Hoc meeting to discuss root cause analysis of the facility's failure to protect a resident right to be free from sexual abuse.
- Social Worker completed abuse questionnaires and abuse education with cognitively intact residents.
- DON and ADON completed abuse audits on cognitively impaired residents.
- RDCS and DON completed abuse questionnaires with all facility and agency staff on the Abuse, Neglect and Exploitation Policy.
- All current facility staff and agency staff were in-serviced on the Abuse, Neglect and Exploitation Policy.
- The facility will no longer admit new residents under fifty-five or those with a homeless status without Ascent Governing Body approval.
- The DON, ADON, UM or SW will complete abuse questionnaires with facility and agency staff to validate understanding of the Abuse, Neglect and Exploitation Policy.
- The Administrator or SW will complete abuse questionnaires with five cognitively intact residents.
- The DON, ADON, SDC or UMs will complete abuse audits with five cognitively impaired residents.
- The Administrator, DON or SW will make rounding observations to identify high risk resident behaviors.
- RDO, VPCQA or RDCS will review Abuse allegations, adherence to the updated admission screening process and the facility corrective action plan.
- Results of monitoring will be presented by the Administrator with the QAPI Committee during QAPI meetings.
Failure to Preserve Evidence in Abuse Investigation
Penalty
Summary
The facility failed to implement its abuse policy and procedures effectively, particularly in the areas of employee training and investigation, by not preserving evidence that could be used in a sexual assault allegation. The incident involved a female resident with severe cognitive impairment and a male resident with moderate cognitive impairment. The male resident was found with his shorts pulled down, lying in bed behind the female resident, whose brief was torn in the back. This situation was perceived as an intention to engage in sexual activity. Upon discovering the situation, Nurse #1 and Nurse Aide #1 provided incontinence care to the female resident and discarded the brief, which could have been potential evidence in a criminal investigation. The facility's policy on abuse, neglect, and exploitation clearly states the importance of not tampering with or destroying evidence that could be used in such investigations. However, the staff involved did not adhere to this policy, as they were focused on maintaining the dignity of the female resident by cleaning her up before she was sent to the hospital for evaluation. Interviews with the staff revealed that they were not adequately prepared for such incidents and did not consider the implications of their actions on the investigation. The Assistant Director of Nursing and the Administrator acknowledged that the staff acted out of concern for the resident's dignity but failed to follow the facility's abuse policy regarding evidence preservation. This oversight affected the integrity of the investigation into the alleged abuse.
Facility Fails to Employ Qualified Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time Social Worker (SW) as required for a skilled nursing facility with more than 120 beds. The facility, which has 134 certified beds, employed a SW who did not possess the necessary bachelor's degree in social work or a related human services field. Instead, the SW held an associate's degree in medical billing and coding and had experience working in SW positions at smaller facilities with less than 120 beds. This discrepancy was identified during a review of the facility's Social Services Director job description and confirmed through staff interviews. The Administrator, who had recently started at the facility, acknowledged awareness of the regulation requiring a qualified SW and admitted that the issue had just been brought to his attention. The Vice President of Operations (VPO) explained that the decision to hire the unqualified SW was due to difficulties in finding suitable candidates. The VPO noted that the facility's Administrator had a bachelor's degree in a human service field and that a full-time SW with a master's degree in social work at a nearby sister facility could provide supervision and support to the facility's SW.
Latest citations in North Carolina
A resident with hemiplegia after a cerebral infarction and chronic atrial fibrillation was receiving rivaroxaban 20 mg daily as an anticoagulant, as documented in active medication orders, the MDS, and the MAR over several months. However, the comprehensive care plan, from admission through a later update, did not include any problem, goal, or intervention related to anticoagulant use. The MDS Coordinator stated she reviews and updates care plans after MDS completion and acknowledged she had overlooked adding anticoagulant use to the care plan, while the Administrator reported an expectation that all high-risk medications, including anticoagulants, be reflected in resident care plans.
A resident with a chronic heel wound with drainage, classified as high risk under the facility’s Enhanced Barrier Precautions (EBP) policy, received wound care from a Wound Nurse and a NA who wore masks and gloves but did not don gowns during multiple high-contact wound care activities on both lower extremities. The facility’s EBP policy requires both gloves and gowns for high-contact care, including wound care, for residents with chronic wounds. At the time of care, there was no EBP sign on the door and no PPE caddie or supplies outside the room. In subsequent interviews, the Wound Nurse and NA reported they did not wear gowns because there was no sign on the door and the nurse was not wearing one, while the IP and DON stated they would have expected gown use and confirmed that wound care is considered a high-contact activity under the policy.
Over more than a year, residents repeatedly reported during Resident Council meetings that call lights were not answered timely, staff sometimes turned off call lights without meeting needs, ice and water were not passed consistently on all shifts, water pitchers were not washed as expected, and care was not always provided during meal times. Residents also described staff using poor attitudes, including cursing and aggressive tones, and noted that coffee on hall carts was often empty or cold at breakfast. Despite these concerns being raised month after month, residents stated they felt the facility only responded by saying staff were being educated, while the same problems continued. The Social Worker and DON acknowledged that these issues had been discussed numerous times without true resolution, and residents expressed a desire for their needs to be met and for clear feedback from administration about efforts to address their ongoing concerns.
A resident was admitted with documented PTSD and COPD, and hospital records showed PTSD as a chronic condition monitored during hospitalization. Although the care plan and MDS admission assessment identified PTSD as an active psychiatric/mood disorder and the resident received an antidepressant, the PASRR Determination Notification reflected only a Level I PASRR, and the FL2 form from the hospital did not list PTSD. The SW, who was responsible for PASRR submissions, relied on quarterly audits of admission paperwork and the MDS to identify cases needing Level II PASRR, resulting in no timely Level II request being submitted for this resident’s PTSD diagnosis.
Surveyors found multiple opened nutritional supplement containers in unit nourishment refrigerators that were either undated or stored beyond the manufacturer’s specified use-by timeframe. A one-quart shake in one unit refrigerator lacked an opening date despite a label requiring use within four days of opening, while two dated one-quart shakes and an opened, undated diabetic shake in another unit refrigerator were not managed according to their labeled time limits. The DM reported that nursing staff, not dietary, were responsible for dating and discarding resident nutritional shakes, while dietary staff only checked and restocked kitchen-provided items. A nurse and the Administrator both confirmed that the person opening the shake was responsible for dating it and ensuring it was used or discarded within the manufacturer’s guidelines.
A resident with ESRD, peripheral vascular disease, and an AV fistula returned from dialysis with a gauze dressing applied by the dialysis nurse, which remained in place into the following day. A physician order and care plan required nursing staff to remove the AV fistula dressing on the night of dialysis and assess the site for complications and signs of infection. The assigned nurse acknowledged she knew she was required to remove the dressing and assess the site but forgot because she was busy with another resident. The physician emphasized the importance of post-dialysis AV fistula assessment due to the resident’s vascular disease and prior complications, and the DON stated she expected staff to follow the order and routinely assess the fistula site.
A resident admitted with bipolar disorder, generalized anxiety disorder, vascular dementia with severe behavioral disturbance, and active BPSD was maintained on multiple psychotropic medications, including an antipsychotic with a documented contraindication to gradual dose reduction, but only had a Level I PASRR on file. At admission, the SW verified that a PASRR existed in NC MUST but did not confirm that the resident’s mental health diagnoses were captured, and no Level II PASRR request was submitted. The SW reported she relied on prior guidance that a Level I PASRR was sufficient unless there was a change in condition, and the Administrator confirmed the SW was responsible for Level II PASRR submissions, resulting in the failure to obtain a required Level II determination.
A resident with dementia, stroke, dysphagia, and severe cognitive impairment, who was edentulous and dependent for ADLs, was care planned and listed on the NA Kardex to receive assisted oral care at least twice daily. Over nearly a month, NA documentation showed denture care was provided only three times, and surveyors observed the resident’s upper and lower dentures with brown stains and debris buildup. One NA, assigned on several day shifts, believed the resident did not have dentures and only offered mouthwash and a basin, while another NA, aware the resident wore dentures, usually did not perform denture care because the resident was already in bed and did not want to remove them. The DON later confirmed the dentures had visible debris and staining and that the care plan required regular oral care and proper denture cleaning.
The facility failed to ensure residents received their mail in a timely manner, particularly mail delivered on Saturdays. During a council meeting, several residents reported that Saturday mail was not brought to them until Monday. The new Activity Director did not work weekends and was unfamiliar with the weekend mail process. The weekday receptionist stated that the weekend receptionist had no key to the outdoor mailbox, so mail was not retrieved on Saturdays unless the Business Office Manager was present. The Business Office Manager confirmed that when she was absent on weekends, no one else could access or deliver residents’ mail, and that after the prior Activity Director left, there was no designated staff to deliver weekend mail, resulting in periods when residents did not receive their mail on the day it arrived.
The facility failed to maintain and implement its antibiotic stewardship and infection surveillance program, as required by its own policy. For most months reviewed, there were no infection control records, including antibiotic order listings, documentation confirming infections, surveillance logs, or trend analyses, and the only available data for one month was an unstructured list of residents who received antibiotics without formal tracking of infection rates or antibiotic use. The DON, who was also expected to serve as the Infection Preventionist, reported being unable to locate infection control reports or surveillance data for an extended period, and the Administrator confirmed that, during a time of multiple interim DONs, infection control tracking and analysis of infection and antibiotic use trends had not been completed.
Failure to Care Plan for High-Risk Anticoagulant Therapy
Penalty
Summary
The facility failed to develop an individualized comprehensive care plan addressing anticoagulant medication use for a resident who had been prescribed rivaroxaban 20 mg daily with the evening meal for a history of cerebral infarction. The resident was admitted with hemiplegia following a cerebral infarction and chronic atrial fibrillation, and the active medication orders showed continuous administration of rivaroxaban from its start date through the survey review period. The quarterly MDS assessment documented that the resident was receiving an anticoagulant, and the Medication Administration Record confirmed daily administration of rivaroxaban over several months. Despite this ongoing anticoagulant therapy and the resident’s relevant diagnoses, the comprehensive care plan dated at admission and updated later did not include any focus area, goals, or interventions related to anticoagulant use. During an interview, the MDS Coordinator acknowledged that the care plan did not address the anticoagulant medication and stated that she must have overlooked it when updating the care plan after completing the MDS assessment. In a separate interview, the Administrator stated that her expectation was that all resident care plans reflect high-risk medications, including anticoagulants.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Infection Control policies and procedures for Enhanced Barrier Precautions (EBP) during wound care for a resident. The facility’s EBP policy, last revised on 04/15/26, requires staff to don both gloves and a gown for high-contact care activities with high-risk residents, including those with chronic wounds. High-contact activities listed in the policy include wound care, and the policy specifies that residents with chronic wounds should remain on EBP for the duration of their stay or until the wound resolves. Resident #12 was admitted with a chronic heel wound with drainage, placing the resident in the high-risk category under the EBP policy. During an observation of wound care on 05/12/26 at 12:33 PM, the Wound Nurse and Nurse Aide (NA) #1 entered the resident’s room wearing masks and gloves but no gowns. There was no EBP sign on the door and no PPE caddie or supplies outside the room. The resident was seated in a wheelchair beside the bed with the door open. The Wound Nurse performed multiple wound care steps on the resident’s right leg, right heel, left third toe, and left heel, repeatedly donning and doffing gloves and performing hand hygiene, while NA #1 assisted by holding the resident’s legs. At no point during these high-contact wound care activities did either staff member wear a gown. In interviews following the observation, the Wound Nurse stated he did not wear a gown because there was no sign on the door indicating the resident was on EBP and later acknowledged learning that a gown should have been worn. NA #1 similarly reported that she did not wear a gown because there was no sign on the door and the Wound Nurse was not wearing one, and she later learned that both should have worn gowns. The Infection Preventionist (IP) stated that the resident should have had an EBP sign on the door and a PPE caddie available, and explained that the sign and supplies were likely left on the resident’s previous room after a move. The IP and the Director of Nursing both stated they would have expected the Wound Nurse and NA #1 to wear gowns while providing wound care, and the DON identified wound care as a high-contact activity requiring gown use under the facility’s EBP policy.
Ongoing Failure to Resolve Resident Council Concerns About Call Lights and Basic Services
Penalty
Summary
The deficiency involves the facility’s failure over a 13‑month period to effectively resolve and communicate resolution of repeated concerns raised in Resident Council meetings, particularly regarding call light response times, staff turning off call lights without meeting needs, inconsistent ice and water pass, and care during meal times. Resident Council minutes from multiple months document that residents, especially those on the 200 hall, repeatedly reported that call lights were not answered in a timely manner and that staff sometimes turned off call lights and left without providing the requested care. Residents also reported that when they turned their call lights back on, staff questioned why they had done so, despite their needs not having been met. These concerns were documented as new issues in successive meetings, indicating that the same problems persisted over time. The Resident Council minutes further show that residents repeatedly complained that ice was not being passed consistently on second and third shifts and on all halls, and that water pitchers were not being washed weekly as expected. At various meetings, residents stated that ice was not being passed daily on all shifts, that ice was not being passed routinely, and that ice was not being passed on every shift. Additional concerns were raised about staff attitudes, including cursing and using an aggressive tone of voice, and about care not being provided during meal times. Residents also reported that coffee on the hall cart was often empty or cold at breakfast. These issues were brought up under both Old Business and New Business in multiple meetings, demonstrating that residents perceived them as ongoing, unresolved problems. During a Resident Council group interview, several residents who lived on the 200 hall and regularly attended the meetings stated they felt the facility did not truly address their concerns because the typical response they heard was that staff were being educated, yet the same problems continued. Multiple residents agreed that call lights not being answered timely was a continual problem and expressed that they wanted resolution and their needs to be met, as well as feedback from administration about efforts made to address their concerns. The Social Worker confirmed that call light response time, passing ice on all shifts, and providing care during meal times had been discussed numerous times and acknowledged there was still no resolution to these issues. The DON acknowledged that grievances from Resident Council regarding clinical issues were assigned to her and that the 200 hall was considered challenging, with residents there being more alert, oriented, and vocal about their needs, but the ongoing nature of the same complaints showed that the facility did not effectively resolve or communicate resolution of the residents’ repeated concerns. The Administrator, who had recently started in the role, stated that they were hoping to achieve resolution of the call light response concerns and that call lights should be answered as quickly as possible, with staff not turning off call lights and failing to return to meet residents’ needs. Despite these stated expectations, the documented Resident Council minutes and resident interviews demonstrate that residents continued to experience and report the same issues over many months. Overall, the deficiency centers on the facility’s inaction and ineffective response to recurring Resident Council complaints, resulting in residents feeling that their concerns about call light response, ice and water service, staff behavior, and care during meals were not being resolved or adequately addressed.
Failure to Request Level II PASRR for Resident With PTSD Diagnosis
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident admitted with a serious mental health disorder. The resident’s hospital course and treatment note documented chronic post-traumatic stress disorder (PTSD), which was monitored during that hospitalization. A PASRR Determination Notification letter showed the resident only had a Level I PASRR with no expiration date. The North Carolina Medicaid FL2 Level of Care Screening Tool completed by the hospital social worker and sent to the facility did not list PTSD as a diagnosis, even though the resident was admitted with diagnoses including COPD and PTSD. The resident’s care plan, initiated shortly after admission, identified a risk for impairments or complications due to a history of PTSD and included interventions such as approaching the resident calmly, avoiding triggers, building a trusting relationship, obtaining psychiatric referrals as needed, and involving the resident in care decisions. The admission MDS assessment indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, but it did list PTSD as an active psychiatric/mood disorder diagnosis and documented that the resident received an antidepressant during the assessment period. The facility social worker, who was responsible for submitting Level II PASRR requests, acknowledged that the resident had a PTSD diagnosis that was not included on the FL2 and stated she conducted PASRR audits on a quarterly basis by reviewing admission paperwork and the MDS to identify diagnoses requiring Level II submission. She reported she was in the process of completing these audits and preparing to submit requests, including one for this resident. The administrator stated that the social worker should have reviewed the admission diagnoses and MDS triggers and requested a Level II PASRR evaluation for the resident’s PTSD at the time of admission or within a month of admission or new diagnosis, rather than waiting for quarterly audits.
Failure to Date and Discard Opened Nutritional Supplements per Manufacturer Instructions
Penalty
Summary
The deficiency involves the facility’s failure to properly date and discard opened containers of nutritional supplements stored in nourishment room refrigerators on the North and South Units. During observations of these refrigerators with the Dietary Manager, surveyors found a one-quart nutritional shake in the North Unit refrigerator with no date indicating when it was opened, despite the manufacturer’s label stating it must be used within four days after opening if refrigerated. In the South Unit refrigerator, surveyors observed two one-quart nutritional shakes dated 4/24 and 4/28, both beyond the manufacturer’s four-day use-by period, as well as an opened and undated 8-ounce diabetic nutritional shake whose label required use within 48 hours of opening. In interviews, the Dietary Manager stated that dietary staff did not stock the nutritional shakes in the nourishment refrigerators and that nurses were responsible for the nutritional shakes given to residents, including dating them when opened and discarding them when past the use-by date. The Dietary Manager also explained that dietary staff checked the nourishment refrigerators twice daily only for items provided by the kitchen, including restocking and checking expiration dates on those snacks and drinks. A nurse confirmed that a physician’s order was required for a resident to receive a nutritional shake and that nurses were responsible for dating the shakes when opened and ensuring they were used and discarded according to the manufacturer’s instructions. The Administrator stated that the person who opened a nutritional shake was responsible for writing the date opened on the container and noted that historically dietary staff checked dates on food and drinks stored in the nourishment refrigerators.
Failure to Remove Dialysis AV Fistula Dressing and Perform Ordered Assessment
Penalty
Summary
The facility failed to follow a physician’s order to remove a dressing and visually assess a resident’s arteriovenous (AV) fistula after dialysis. The resident, who had diagnoses including AV fistula, end stage renal disease, dialysis, and peripheral vascular disease, was cognitively intact and received dialysis. A physician order dated 2/2/2026 directed staff to remove the dressing to the AV fistula on the night of dialysis every Monday, Wednesday, and Friday to avoid skin breakdown and damage to the AV fistula. The resident’s care plan, updated on 2/27/2026, included interventions to check and change the AV fistula dressing as ordered and to observe the site for signs and symptoms of infection. On observation, the resident was noted to have a gauze dressing with tape on the left upper arm AV fistula the day after dialysis, and the resident reported that the dressing had been applied by the dialysis nurse after treatment. The nurse assigned to the resident on the 3:00 PM to 11:00 PM shift acknowledged that she was supposed to remove the dressing and assess the AV fistula site when the resident returned from dialysis but stated she forgot because she was busy with another resident. The physician stated that it was important for nursing staff to remove the dressing and assess the AV fistula after dialysis due to the resident’s significant vascular disease and history of complications with hypotension and falls after dialysis, and described the AV fistula as the resident’s lifeline. The DON stated that nursing staff usually removed the dressing and assessed the AV fistula site after dialysis and that she expected staff to follow physician orders and assess for signs and symptoms of infection.
Failure to Request Level II PASRR Evaluation for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to submit a request for a Level II PASRR evaluation for a resident admitted with serious mental health disorders. A PASRR Determination Notification letter showed the resident had only a Level I PASRR with no expiration date. The resident was admitted with diagnoses including bipolar disorder, generalized anxiety disorder, and vascular dementia with severe behavioral disturbance. A psychiatric progress note documented a long history of bipolar disorder and recent behavioral and psychological symptoms of dementia, with active diagnoses of bipolar disorder, bipolar depression, and generalized anxiety disorder. The resident was receiving multiple psychotropic medications, including duloxetine, clonazepam, quetiapine (in both morning and bedtime doses), and trazodone. The admission MDS assessment indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, despite active psychiatric/mood disorder diagnoses of anxiety disorder and bipolar disorder and ongoing antipsychotic use with a physician-documented contraindication to gradual dose reduction. An NC MUST inquiry confirmed that only a Level I PASRR, effective more than a year prior, was on file and that no PASRR requests for a Level II determination had been submitted prior to the survey date. The Social Worker reported that she checked NC MUST for a current PASRR at admission but did not verify whether mental health diagnoses were included in the initial screening, and she relied on prior guidance from a PASRR evaluator that a Level I PASRR was sufficient unless there was a change in condition. The Administrator stated the Social Worker was responsible for submitting Level II PASRR requests and acknowledged that, based on this prior guidance, a Level II request for this resident was not completed.
Failure to Provide Ordered Denture and Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide ordered assistance with denture and oral care for a dependent resident with severe cognitive impairment, dementia, stroke, dysphagia, and edentulism. The resident’s admission MDS documented severely impaired cognition, a need for setup or clean-up assistance with oral hygiene, and no refusal of care or behaviors. The care plan and NA Kardex both directed staff to provide or assist with oral care at least twice daily using a soft toothbrush or foam swabs, and identified the resident as at risk for oral and dental health problems and dependent in ADL self-care. However, NA documentation showed denture care was recorded as provided only three times over nearly a month-long period. During observation, the resident reported wearing upper and lower dentures and displayed dentures with brown stains and debris buildup around the teeth and gums, stating he could brush his dentures if he had a toothbrush and toothpaste. One NA, assigned on multiple day shifts, stated she provided only mouthwash and a basin because the resident had difficulty brushing, believed the resident did not have dentures, and confirmed she had not provided denture care. Another NA on night shift acknowledged knowing the resident wore dentures, having seen them on the bed or nightstand, but stated she usually did not perform denture care because the resident was already in bed and did not want to remove them, and described denture care only as soaking them overnight. When the DON later observed the dentures, he confirmed visible debris and brown staining, and acknowledged that the care plan and Kardex required oral care at least twice daily and that dentures should be brushed and soaked overnight.
Failure to Ensure Timely Weekend Mail Delivery to Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ right to receive mail, including mail delivered on Saturdays. During a Resident Council group interview, several residents reported that when mail was delivered to the facility on Saturdays, it was not distributed to them until Monday by the Activity Director. Multiple residents agreed with this account, and no residents present disagreed. The new Activity Director, who had transitioned from working as a Certified Occupational Therapist Assistant on 04/24/26, stated she did not work weekends and was unsure how mail delivery to residents was handled on weekends. Staff interviews further showed that the weekend receptionist did not have a key to the outdoor mailbox and therefore could not retrieve Saturday mail. The weekday Receptionist reported that she collected the mail from the outdoor mailbox on Monday mornings and gave it to the Business Office Manager, after which the Activity Director delivered it to residents. The Business Office Manager confirmed that if she was not at work on weekends, no one else had access to the outdoor mailbox. She stated she worked most Saturdays, checked and sorted the mail, and then gave residents’ mail to activity staff or delivered it herself, but noted that after the previous Activity Director left 6–7 weeks earlier, there was no one designated to deliver mail to residents on weekends when she was not present. The Administrator acknowledged that there were approximately three weeks when weekend mail was not delivered to residents due to turnover in the activity department and the absence of an Activity Director.
Failure to Maintain Facility-Wide Antibiotic Stewardship and Infection Surveillance
Penalty
Summary
The facility failed to implement a facility-wide system to monitor antibiotic use as required by its Antibiotic Stewardship Program policy. The policy, last revised in December 2016, required that all clinical infections treated with antibiotics undergo review by the Infection Preventionist or designee, including review of antibiotic utilization, antibiotic orders, clinical documentation confirming infections, infection surveillance logs, microbiology testing, and trends in infection and antibiotic use data. Surveyors found that for eight of nine months reviewed—July, August, September, October, November, and December 2025, and February and March 2026—the facility was unable to provide any infection control data, including listings of antibiotic orders, clinical documentation confirming infections, surveillance logs, or trending of infections. For January 2026, the facility had only a list of residents who exhibited symptoms and were treated with antibiotics, but did not use a structured tool to track infection rates, antibiotic use, or to monitor, conduct surveillance, or identify trends related to infections or possible infections. During interviews, the DON, who assumed the position on April 13, 2026 and was also expected to function as the Infection Preventionist, reported being unable to locate Infection Control reports, surveillance records, or infection tracking data for July 2025 through April 2026, except for the January list of residents who received antibiotics. The Administrator confirmed that multiple interim DONs had served since July 2025 and acknowledged that tracking of infection control data, including infection trends and antibiotic use, had not been completed, despite the facility’s stated intent for a comprehensive Infection Control Program that included surveillance, tracking, and trend analysis.
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